Do we choose not to hear the suffering?

This blog is written in honour of the unheard.

It was Arundhati Roy who observed that there is actually no such thing as the voiceless (apart from elective, acquired or congenital mutes) – instead she says that there are only ‘the preferably unheard’'.

Of course, we can easily reply to her that we do hear story after story of human calamity or catastrophe in our media, and this is true - but it’s also true that these stories come to us through a mysterious filter system, meaning that some stories get heard, while others get curiously ignored. So why do some stories pass muster in the international media, and some not? Who exactly are the arbiters of taste in this field? And do we ourselves complete this filtering by selectively focusing on some crises more than others (either consciously or sub-consciously)?

Haiti may have hit the headlines after its awful earthquake in 2010, for instance, but its 2018 food crisis and ongoing current political turmoil now barely makes the news at all with the situation there continuing to deteriorate. So who has decided that Venezuela now deserves so much of the media spotlight for a not dissimilar crisis in the same hemisphere instead, and do we play a part in this ourselves?

Among other things, the report points out, for instance, that human displacement in the Democratic Republic of Congo (DRC) rivals the immensity of scale of Syria’s. Given the scale of human displacement both within and out of Syria along with all the human tragedy that accompanies it (and the media focus on it), it’s surely odd that no similar stories are being reported from the DRC and its neighbouring countries.

Is it, perhaps, because Syria is more local to us? – or because Syria’s refugees have made such a huge impact on European sensitivities and sense of security? This may well be the case, but this aspect is rendered more interesting still given that CARE reckons that four out of five of the world’s refugees who have been displaced have got nowhere near the borders of Europe, the U.S. or Australia at all: they’ve actually been finding refuge in developing countries (which sadly have least resource to offer succour and support to them).

Or is it for other even darker reasons?

CARE’s analysis was developed as a result of reviewing 1.1 million online articles published in English, German and French. Their criteria for any crisis to be included in their analysis was that it must have affected at least 1 million people, and any articles they analysed about them had to have been published between January and the end of November in 2018. In the end they came up with a list of the ten most ignored (or in Ms Roy’s words ‘preferably unheard of’) crises of 2018. (There were a total of 34 crises, incidentally, that met their criteria in 2018, of affecting over 1 million people so their list comprises a third of the world’s largest humanitarian disasters).

So here is CARE's own graphical representation:

And here is the list presented another way, this time from the least reported (Haiti) through to Sudan:

Haiti: half of the population still earns less than US$1 per day; and because of extreme weather and natural disaster 2.8 million Haitians needed assistance in 2018.

Ethiopia (hunger): recurrent droughts and land degradation exacerbated by climate change mean that around 8 million people still urgently require food assistance.

Madascar: 1.3 million are currently at risk of hunger following extreme weather events, and half of all Malagasy children are currently stunted because of under-nutrition.

Democratic Republic of the Congo: violence has resulted in declining agricultural activity meaning that some 12.8 million people now face the threat of hunger including 4.3 million children (of whom at least 1.3 million are suffering from severe malnutrition); meanwhile more than ¾ of a million Congolese fled to neighbouring countries in 2019.

Philippines: a category 5 cyclone with winds of over 200 kph made landfall in 2018 affecting 3.8 million people and leaving over a million people displaced.

Chad: more than four million people had only limited access to food in 2018, rendering Chad the second hungriest country in the world. Meanwhile Lake Chad is now less than a twentieth of its previous size, and (to make matters even worse) nearly half a million people have crossed into Chad as a result of conflict in neighbouring countries because of Chad’s relative political stability.

Ethiopia (displacement): no country saw more people internally displaced because of conflict in 2018 than Ethiopia (mostly just between April and July).

Niger: desertification, chronic food insecurity and mass displacement with an influx of refugees has confirmed Niger as having the lowest ranking in the Human Development Index with 1.4 million still struggling to survive.

Central African Republic: about 2.9 million people, or more than 60% of the population, are currently in need of aid and desperate for food.

Sudan: following 15 years of poverty, war and climate shock, 5.5 million people are on the edge of starvation.

These are all huge crises, so why have they been so overlooked? CARE offers some suggestions: crisis overload, lack of media access, funding woes, dwindling news budgets for foreign correspondents etc. They don’t mention that nine of these ten crises affect populations which are black, which we think also might possibly be a reason given that black lives don’t always matter as much as they should do. But they also offer more complex explanations relating to our own attitudes which are worth us considering.

In a recent survey, for example, 61% of respondents from 12 countries said that there were simply too many humanitarian crises to keep up with in the world today. Many of us will agree with this but more than half of those responding to the survey felt that they keep hearing the same stories and that coverage focuses on the same countries all the time which (given the list above) plainly shouldn’t be the case. What’s more, they commonly got some key issues seriously wrong as well, assuming that developed countries host the most refugees when in fact over 80% of the world’s refugees currently live in developing countries.

The report also identifies two worrying consequences and complexities that arise from this lack of media coverage.

Firstly, when human suffering is ignored the associated crisis remains tragically underfunded; and secondly, in many cases journalists are actually prevented form reporting the crisis concerned either deliberately (because of actions of politicians) or because of intrinsic danger.

Climate Change

But there is one aspect of this report that really worries us – relating to the amount of neglected human suffering that can now be directly attributed to climate change. This is because CARE directly links five of these neglected crises to climate shock (Sudan, Chad, the Philippines, Madagascar and Ethiopia, and they could have reasonably added many of the problems in Haiti to it as well). So here’s a very inconvenient question for us to consider: might we already be turning our eyes away from the effects of climate change on the world’s poor – on those very people most at risk from its effects but who have contributed least to its causes?

And if so, is this because (in Arundhati Roy’s words) we may prefer not to hear their distress?

We think we should all surely be thinking about this.

What this may mean for all of us

Two questions arise for us from these reflections:

Is our elective deafness likely to change?

Are these frightening levels of humanitarian crises (34 in the year in question with 10 of them so tragically now part and parcel of the world we are living in)?

With regard to question 1, we would certainly argue that it can do – and we would refer you to CARE’s report itself in which they suggest several ways in which it might do so in respect of distinct angles (international media, policy makers and civil society).

The answer to question 2 is unfortunately uncertain and far more worrisome. For a couple of decades it has been being proclaimed with some confidence that levels of poverty are slowly reducing. It’s not completely clear whether this has really been the case, however, certainly if poverty is calculated from median incomes given that in many developing countries the wealthier have got significantly wealthier whilst prices have been rising, and the economic prosperity of the poor has largely remained the same if not worse.

But a new picture is emerging which suggests that poverty may actually be increasing now because of exactly the causative factors identified in CARE’s list above: climate change, conflict, displacement of people and other natural disasters. In fact it's difficult to argue that the stresses from each of the first three factors aren't currently increasing, and of course the consequences of each of them are hardly being helped by aid agencies being stretched beyond reason. Nevertheless, each of them can still be dealt with by measured political action (or with emergency political action in the first case), but we appear unfortunately to be living now in an era where measured action is in short supply.

It’s worth bearing in mind one of the forecasts made by the World Bank for the Sub-Sahara if we see a temperature hike of 2 degrees centigrade: a 40-80% loss of crop growing areas. It’s hard to imagine the stresses these crop losses are going to impose on the region.

What this may mean for healthcare?

Climate change, conflict, displacement of people and natural disasters all add up to impoverishment, and impoverishment adds up to weaker immune systems in those most affected by it, and weaker immune systems make for more sickness in populations already potentially suffering from respective primary disasters.

What this means in turn is that the chasm of provision of health care that already exists for the poor in comparison to the wealthier must be inevitably widening.

And for tuberculosis?

Well for any of us working in the field of tuberculosis, these factors together scream out that the incidence of ‘latent’ (sub-clinical) TB infections re-activating into active infectious lethal disease is likely to rise.

The latest global estimates reckon that 23% of humanity is currently latently infected with tuberculosis[i] (i.e. roughly one in four of us). That’s shocking enough but, of course, most of these 1.7 billion odd people live in TB endemic countries (where they’ve been exposed to the mycobacteria). In other words, they may not live on our doorsteps if we live in the Global North, and so this percentage varies wildly across the geo-political spectrum – in fact the vast majority live in low-income countries or are amongst the hosts of the poor in middle-income ones.

Normally, it’s reckoned that between 5% and 15% of those who are latently infected will develop the active infectious disease – but again this varies wildly and this time is largely dependent on the health of the host’s immune system. Unfortunately, it’s still not fully understood what finally triggers the bacteria to re-activate, but various factors are known to predispose this to happen, and (once again) many of them are potentially aggravated by poverty.

Meanwhile, given that 67 million children are currently reckoned to be latently infected with TB (2 million of them with drug-resistant strains), it’s easy to imagine the massive reservoir of potential disease that's already in existence.[ii] All the disease needs (as it has done from time immemorial) is for the right factors to exist to facilitate it.

The current target, meanwhile, is to ‘end’ TB by 2030, but this target is just one of many in the list of Sustainable Development Goals (in fact it’s the third target of goal 3 which relates to health and well-being). There’s no point pretending that meeting most (if not all) of the other sixteen goals[iii] is the most critical part of driving down the numbers of new TB cases because so much of TB is determined by social factors. Of course we need better diagnostics, and of course we need new drugs (given that the disease is becoming increasingly resistant), but we also need less conflict, less displacement of people, and above all we need less poverty and to rapidly get a handle on climate change or everything is plainly going to get significantly worse.

Tuberculosis has been appallingly neglected – there’s no doubt about this. Whilst it was driven down in the Global North (partly because of drugs, but mainly because of improving socio-economic conditions including better nutrition) it was allowed to fester in the Global South right through the 20th century. But it’s not just been festering away in numbers that are only now beginning to be finally recognised (with the disease being regularly retrospectively re-estimated upwards as new surveillance has revealed more disease than was previously reckoned to exist); it’s also morphed into a second clinically distinct disease that is drug-resistant and particularly dangerous.

Have we heard much about this in the media? The answer to this is ‘not much’ – certainly in respect of the scale of suffering that TB has been causing. In this respect, in fact, TB falls into exactly the same category as CARE’s ten most neglected crises of 2018 as another case of 'silent suffering' – particularly if you consider that (despite the disease being curable in the vast majority of cases) it’s been claiming an average of two million victims a year for the last quarter century.

You heard of swine ‘flu in the media, didn’t you? (285,000 victims). You heard about SARS? (1,000 victims). You heard of ebola? Of course you did! (11,000 victims in the West African outbreak that scared the whole world rigid). You’ve definitely also heard of HIV/AIDS (40 million deaths since its outbreak, but with the deathtoll now slowly being driven downwards). But have you really heard that much about TB (with at least 50 million lives lost to it since it was officially declared an official Global Emergency in 1993), or indeed about MDR-TB (with 75 million lives projected to be lost to its drug-resistant form by 2050).

World TB Day 2019

On March 24th the world will wake up to yet another World TB Day (the 137th anniversary of the day when the mycobacterium was first identified in Berlin in 1882). And yet again most of the world will probably hear little about this disease in the mainstream media.

The Stop TB Partnership strives really hard to change this, each year coming out with a new slogan to try to wake the world up to the scale of this neglected problem. This year they’ve excelled themselves, coming up with the simple slogan ‘IT’S TIME…’ – encouraging us all to complete the sentence in our own words and upload a selfie about it on social media.[iv]

So what’s it time for now?

Well for us at Moxafrica it’s time to get moxa really put to the test against MDR-TB – to see the findings of the Ugandan study (which looked at the use of adjunctive moxa for TB cases) followed up by rigorous testing of the findings of the North Korean Ministry of Health’s own study (which looked at the responses of MDR-TB cases who benefited significantly from a higher dosage of moxa).

But given what Arundhati Roy suggests of us, given what the CARE report reveals, and given the content of this blog, what is it time for for you now?